In July, 1907, the Swiss psychiatrist Carl Gustav Jung and American neurologist Frederick Peterson published the results of their investigations into the galvanometer and the pneumograph in BRAIN, the journal of neurology. The pair had subjected various people to these instruments—people they had identified as “normal” and “insane”—in an attempt to record and quantify certain “emotional” and “psychical changes” in their moods “in connection with sensory and psychical stimuli.”1 At this time, only a few years into the twentieth century, these scientists—and many others like them—were eager to develop a systematic means of measuring emotion. They sought to demystify and provide a scientific explanation for the enigmatic interface between the body’s nervous system (both the peripheral and central nervous systems) and the presentation of varied human emotions. To this end, instruments such as the galvanometer and pneumograph, then understood as effective “measurer[s] of the emotional tone,” promised to illuminate the physical meanings, mechanisms and perhaps even causes of what they called the “emotional complexes.”2

Among the most extreme of the “emotional complexes” was the category of dementia praecox. This was a condition whose “chief characteristic” was, as George H. Kirby noted, “a particular disturbance of the emotions.”3 Kirby was the first American to develop a classification of psychoses, and his system was later adopted by the American Psychiatry Association in something of a precursor the Diagnostic Statistical Manual of Mental Disorders, the authoritative diagnostic manual used by psychiatrists today. But Kirby was not the first twentieth-century psychiatrist to undertake a modern classification of the psychoses. That honour belonged to Eugen Bleuler, the Swiss psychiatrist under whose supervision Jung and Peterson had conducted their work on the galvanometer and the pneumograph. In fact, Jung and Peterson undertook their research in Bleuler’s laboratory, within the huge University Clinic for Psychiatry at Zurich known as Burghölzli (fig. 1), a building that was idyllically depicted in 1917 by swiss painter Max Gubler (fig. 2), who would tragically later move and die there.4 In Burghölzli, Jung and Peterson also used Bleuler’s apparatuses—his galvanometer and the pneumograph—to produce their study of the relations between the nerves and emotions. Jung had been awarded his PhD in 1902 based on Bleuler’s reports, and the tense relationship between the two men has been a subject of some scholarly interest.5

Figure 2. Max Gluber, Winterlandschaft Burghölzli [Winter Lanscape at Burghölzli] (1917). Courtesy of the Eduard, Ernst and Max Gubler Foundation.In 1911, only four years after the publication of Jung and Peterson’s investigation, Bleuler would coin the term schizophrenia, proposing that it should replace “dementia praecox.” That older term had been coined by the French physician or “alienist” Phillippe Pinel in the early nineteenth century, and popularised by the influential German psychiatrist Emil Kraeplin in his 1896 textbook Psychiatrie. In Bleuler’s 1911 monograph, titled Dementia Praecox or the Group of Schizophrenias, the Swiss psychiatrist would argue that the earlier term was misleading for practitioners, conveying as it did two deceptive associations. The term, he said, suggested that schizophrenia had something to do with the disease of dementia, as well as with the concept of “precocity,” when in fact it had nothing to do with either. Moreover, Bleuler argued that it was impossible to express the phrase “dementia praecox” as an adjective, which made writing about the disorder nearly impossible.6

Despite the fact that Jung and Peterson worked in Bleuler’s laboratory, the way in which these scientists described mental disorders differed markedly, at least in one respect. Strikingly, Bleuler’s paradigmatic psychiatric work of 1911, translated into English from the original German in 1950, almost entirely omits the word “emotion” or “emotional complex.” By contrast, Jung and Peterson’s study of 1907 uses the term “emotion” or “emotional” some 108 times (in a study of roughly 18,000 words). Of course, this is not to say that emotions are altogether excluded from Bleuler’s understanding of schizophrenia. On the contrary, emotions lie at the heart of his symptomatological description of the disorder. At one point in his monograph, Bleuler writes that “many schizophrenic symptoms originate from emotionally charged complexes” and that the “symptomatology is determined by the emotionally charged complex which, in turn, is often dependent on the Anlage [predisposition].”7 As such, the omission of the word emotion and the general concept of emotionality in Bleuler’s text is puzzling. Of course, it might be explained by the fact that there is no easy German equivalent to the word, and that the text would presumably employ the word “gefühl” (meaning feeling) or “affekt” (meaning affect) to denote the same concept.

Indeed, as psychiatry developed in the following decades, the concept of “feeling” and specifically of the “praecox gefühl”—the praecox feeling—would become one of the most important in the diagnosis of the psychoses. First named by the Dutch psychiatrist H. C. Rümke in the 1940s, the praecox feeling described the way in which the diagnostician would, in some circumstances, need to rely on intuitive reasoning—on their highly attuned and sensitive emotional senses, refined as they were by clinical experience—to reach a diagnosis of schizophrenia. It would be necessary to use this method when a patient was, for reasons related to their pathology, “fundamentally inaccessible,” such as when, because the basic structure of their “being-in-the-world” had altered, the practitioner could identify something about them that was hard to describe in words but “definitely incomprehensible.”8

Perhaps one of the reasons that Bleuler’s work so rarely refers to emotions and emotional states, whereas Jung and Peterson’s study describes “emotions” so often, is due to the divergent aims of and influences on their authors. Despite presenting itself as a work of psychiatry, Bleuler’s study inherits much from psychoanalysis and Freud, routinely referring to such Freudian concepts as symbolisation, resistance, and the Oedipus complex, among others. Jung and Peterson’s study, by contrast, focuses almost entirely on the quantification of emotions by means of their instruments; it is less a study in taxonomy than an attempt to break away from those symbolic concepts that Freud had introduced only six years earlier. Using instruments and devices, Jung and Peterson seek to bring these disorders of the mind out of the realm of the “invisible” and into the clear light of day. This, as Jeffrey Lieberman notes, was precisely what distinguished the work of neurologists from psychiatrists: “Physicians who specialized in disorders with an observable neural stamp became known as neurologists,” he writes, whereas “those who dealt with the invisible disorders of the mind became known as psychiatrists.”9

Historians and philosophers of science have identified the rise of a “device paradigm” in psychiatry from the mid-twentieth century and onward. They point to the invention of electroconvulsive therapy (ECT), the emergence of repetitive transcranial magnetic stimulation (rTMS) and, from the mid-1950s, the use of psychopharmacological drugs, as evidence of this newly device-oriented science of the mind.10 However, Jung and Peterson’s investigations—together with some similar, though more controversial, experiments with x-rays in chiropractic medicine—illustrate an earlier turn towards devices. In fact, not only was the shift toward devices well underway in the first decade of the twentieth century, but devices were, at this time, central to the study of emotion. Before psychiatrists such as Bleuler and Kirby established psychiatry’s classification systems, subsuming “emotional complexes” into their systematic taxonomies, measuring human emotions by means of physical tests had been a central object of neurological enquiry.11

Figure 3. The most recent version of the E-Meter (courtesy Scientology.org).

Ironically, Jung and Peterson’s methods would be revived in the 1950s, when, after attending a lecture delivered by L. Ron Hubbard, an American inventor named Volney Mathison patented a new device that he described as a “bio-electronic instrument which registers human dynamic emotion in a more accurate and sensitive manner than has been possible with any previous device of comparable simplicity.”12 Hubbard quickly embraced the device, which is now known as the E-meter (fig. 3, above), and a modified version of this same galvanometer today forms part of the Church of Scientology’s official practices, used to “audit” the emotional complexes of the Church’s adherents.13

This article was originally published on The Conversation, here. I have altered the styling slightly.

In the late nineteenth century, Sigmund Freud’s colleague Wilhelm Fleiss successfully diagnosed an illness in one of Freud’s relatives, without even having met them. Freud was so impressed by Fleiss’s “diagnostic acumen” that he went on to advocate the method in certain circumstances. Freud would write that diagnosing someone without personally examining them was acceptable where the features of certain disorders, such as paranoid schizophrenia (then known as dementia paranoides), made the interview process counterproductive. Here, Freud noted that “a written report or a printed case history can take the place of personal acquaintance with the patient.”

Now, a controversial debate about the ethics of diagnosis at a distance or long-distance diagnosis has arisen in the US. It has come about as commentators have proposed that President Donald Trump suffers from narcissistic personality disorder(NPD) and attention deficit hyperactivity disorder (ADHD), among other conditions. Health professionals have weighed in as well. Psychotherapist and former assistant professor of psychiatry John D. Gartner has been particularly vehement in his assessment of the President. Gartner asserts that Trump suffers from malignant narcissism, a specific manifestation of NPD.

According to the DSM-5—the authoritative psychiatric manual—this condition is characterised by various “traits of antagonism”, including “manipulativeness, deceitfulness, [and] callousness.” Notably, the DSM-5 names the condition only once throughout its hundreds of pages; and some academic psychiatrists say the disorder is understudied and its features largely unsettled, with no treatment yet established.

Despite this, Gartner is convinced that the president’s conduct fulfils the criteria of malignant narcissism—even without having interviewed him:

We’ve seen enough public behaviour by Donald Trump now that we can make this diagnosis indisputably.

Recently, the American Psychoanalytic Association (APsaA) issued a memo to its more than 3,500 members, advising they were “free to comment about political figures as individuals”, and that the APsaA did not regard “political commentary by its individual members an ethical matter.”

By contrast, the American Psychiatric Association (APA) has long maintained a strict ethical stance on the open discussion of public figures’ mental states. Enshrined in the so-called Goldwater rule, the APA’s prescription cautions psychiatrists against diagnosis at a distance. As former APA President Herbert Sacks put it, psychiatrists should avoid engaging in “psychobabble,” especially when it comes to politicians. He said that, when “reported by the media,” such diagnostic speculation only “undermines psychiatry as a science.” Although the Goldwater rule is not enshrined in Australian law, a code of ethics provides guidance to Australian psychiatrists about their conduct in the media.

What is the Goldwater Rule?

The Goldwater rule is named after an incident involving Republican presidential nominee Barry Goldwater. Having been defeated in the 1964 US election, Goldwater sued the editor of the shortlived political magazine Fact for defamation. Just one month before the election, Fact’s front page had printed a controversial declaration:

1,189 psychiatrists say Goldwater is psychologically unfit to be president!

Fact had conducted a broad but clinically invalid survey, providing questionnaires to more than 12,000 psychiatrists whose details the magazine had obtained from the American Medical Association’s membership list. Of the 2,417 responses it received, some 1,189 psychiatrists asserted Goldwater was unfit for office.

In the feature article, Fact purported to quote many of the psychiatrists it had surveyed, and used their words to suggest that Goldwater was a “megalomaniac, paranoid, and grossly psychotic”, and even suffering from “schizophrenia.” In the trial that followed, Goldwater was awarded some US$75,000 in punitive damages—enough to ensure that Fact never published another issue. The ruling raised disturbing questions for the APA, threatening not only the reputation of the psychiatric profession, but the future livelihoods of practitioners. In slightly different circumstances, a psychiatrist might face similar civil action, whether “for invasion of privacy or defamation of character.”

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general.

However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

The Rule in Dispute

Many academic psychiatrists disagree with the rule. Some have suggested that breaking the Goldwater rule is ethical when it’s necessary to diagnose “mass murderers” from afar, or when “the importance of the diagnosis of an individual … rise[s] to the level of a national threat.” Others have criticised the rule more generally, calling it “an excessive organisational response” to “an inflammatory and embarrassing moment for American psychiatry.” And one psychiatrist has recently described the prescription as “American society’s gag rule.” In February this year, the New York Times published a letter signed by some 33 psychiatrists who blamed the rule for silencing them at this “critical time”. They wrote that “too much [was] at stake to be silent any longer”, and that Donald Trump’s “emotional instability” had made him “incapable of serving safely as president.”

The tension between the APA and its members, and between the APA and the APsaA, partly reflects the history of the two disciplines. Since the 1940s, psychiatry has increasingly focused on medical interventions, while tending to neglect the “in-depth talk therapies” which, despite their general decline, remain central to the psychoanalytic method.

But the situation is still more complicated than this. After all, the methods of psychiatrists and psychoanalysts often overlap. In many practices, for instance, psychiatrists employ intuitive reasoning in the diagnostic process. For some diagnosticians, the so-called “Praecox-Gefühl” or “praecox feeling” remains at the “clinical core” of diagnosing schizophrenia, despite the method’s varied reliability. First described in the 1940s, the praecox feeling is a complex, emotionally charged intuitive sense that a psychiatrist sometimes gets when detecting the subtle symptoms of an emergent psychosis.

What now for the Goldwater rule?

That psychoanalysts may wish to distinguish themselves from psychiatrists on the Goldwater rule, and vice versa, is unsurprising. In countless ways—more than can be named here—psychoanalysts and psychiatrists adopt different views of their roles in the diagnostic process. This is the result of their different training backgrounds, histories, and professional cultures.

Less expected, however, is the growing feeling among psychoanalysts and psychiatrists alike, that today, more than ever, the Goldwater rule should be set aside. While neither group may wish to admit it, the Trump era may have brought psychiatrists and psychoanalysts closer together—at least on this point.

I recently submitted the following abstract to the organisers of a conference called Neuroscience and Society: Ethical, Legal and Clinical Implications of Neuroscience Research, an event scheduled for mid-September, 2017, in Sydney. Since there’s apparently only a very limited pool of speakers, I’m not sure if my paper will be accepted for presentation. But the organisers have also noted that they will invite some attendees to develop posters for the conference; so, if I’m asked to do so, perhaps I’ll make a poster to outline my findings. (It would neatly dovetail my interest in design and research.) Some speakers will also be invited to submit their papers to Neuroethics—one of the journals I had in mind when I began this work (another was the Journal of Law and Medicine). Even if I’m not one of the lucky speakers, I think I’ll ultimately submit the article (of which this abstract forms a part) to Neuroethics.

As always, please do not use or reproduce this work without my express consent or permission. If you wish to quote from this work, please cite this website and this post. In CMoSstyle (for instance), use the following citation: Chris Rudge, “Pain in the Brain: Worker’s Compensation Claims for CRPS-I in Australia (Abstract),” Literature Law, Psychiatry, Politics: Notes by Chris Rudge (blog), July 18, 2017, http://www.rudge.tv/pain-in-the-brain/.

Pain in the Brain: Worker’s Compensation Claims for CRPS-I in Australia

Abstract

Neuroscientists disagree about the underlying mechanisms of chronic regional pain syndrome (CRPS), a debilitating neurological condition characterised by severe pain in the limbs. In CRPS type I, the patient typically suffers from an acute form of pain—one that is frequently not accompanied by any tissue damage or nerve lesion, and is typically disproportionate to the trauma that has incited the condition. These clinical paradoxes make CRPS-I a confounding disorder not only for scientists in medical settings, but for judges, tribunals, and claimants in legal settings.

My analysis of Australian neurolaw, undertaken in the context of working on the Australian Neurolaw Database, has revealed the high incidence of worker’s compensation claims brought in Australia by plaintiffs diagnosed with CRPS-I. While the majority of these plaintiffs are unsuccessful in attaining compensation (with most injuries found to be psychological or psychiatric, not physical or neurological, impairments), this paper analyses these tribunals’ processes, together with the legislative schemes that shape their statutory interpretation of neuroscientific evidence, to show how the legal system impacts on the assessment of chronic pain disorders, and raises crucial questions of great neuroethical import.

To compare these Australian legal cases to developments in the US, this paper will also detail a fascinating US worker’s compensation dispute of 2007 in which both the plaintiff and the defendant appointed separate pain experts to give evidence for their legal claims. What followed was a public disagreement between two distinguished professors of neuroscience about whether the plaintiff’s chronic pain could be detected in BOLD-contrast images (via fMRI). When the judge rejected a motion brought by the defence that that the plaintiff’s evidence was inadmissible—evidence that proposed chronic pain could be detected by fMRI—the defence settled the claim for an amount reportedly more than ‘ten times’ its original offer.

See Anders Möller, Christian Scharfetter and Daniel Hell, “Development and termination of the working relationship of C. G. Jung and Eugen Bleuler, 1900–1909,” History of Psychiatry 13, no. 52 (2002): 445–453.

See Eugen Bleuler, Dementia Praecox or the Group of Schizophrenias, tr. Joseph Zinkin (New York, International Universities Press, 1950).

See James Phillips, “Technology and Psychiatry,” in The Oxford Handbook of Philosophy and Psychiatry, ed. by K. W. M. Fulford, Martin Davies, Richard Gipps, George Graham, John Sadler, Giovanni Stanghellini and Tim Thornton (Oxford: Oxford University Press, 2013), 178.

For the use of x-rays in chiropractic, for instance, see B. J. Palmer’s inventions, as summarised by Simon A. Senzon in “Chiropractic and Energy Medicine: A Shared History,” Journal of Chiropractic Humanities 15 (2008): 27–54.